A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client complains of chest pain & short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse- midwife to her concern that the client may be experiencing:
pulmonary embolism.
mitral valve collapse.
upper respiratory infection.
thrombophlebitis.
The Correct Answer is A
A. Pulmonary embolism (PE): PE is a life-threatening condition that occurs when a blood clot travels to the lungs, often originating from a deep vein thrombosis (DVT). Postpartum clients are at increased risk due to hypercoagulability. Symptoms include sudden-onset dyspnea, chest pain, tachypnea, tachycardia, and hypoxia despite clear lung sounds. This warrants immediate intervention.
B. Mitral valve collapse: This is not a common postpartum complication and does not explain the client’s acute symptoms.
C. Upper respiratory infection: URIs present with cough, congestion, fever, and abnormal lung sounds, which this client does not have.
D. Thrombophlebitis: This refers to localized inflammation of a superficial vein, which may cause leg pain and swelling but does not typically result in respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Respiratory rate of 16 breaths/min: Normal range, no intervention needed.
B. Pulse of 120 beats per minute: Correct. Tachycardia in the postpartum period can indicate hemorrhage or hypovolemia, requiring immediate assessment and intervention.
C. Temperature of 98.8°F (37.7°C): Normal postpartum temperature.
D. Blood pressure of 120/88 mmHg: Normal postpartum blood pressure.
Correct Answer is B
Explanation
A. Remove the client's bra: Incorrect. A well-fitted supportive bra helps reduce discomfort and swelling. Removing the bra may increase pain and worsen engorgement.
B. Alternate with warm compresses and ice packs to the breasts: Correct. Warm compresses before breastfeeding help with milk flow, and cold compresses after feeding reduce swelling and discomfort.
C. Administer acetaminophen as prescribed: Incorrect. While pain relief can help, it does not directly address the engorgement.
D. Limit breastfeeding to twice a day: Incorrect. Frequent breastfeeding or pumping is encouraged to relieve engorgement.
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